New Delhi: There is nearly 80 percent shortage of specialist doctors at community health centres (CHCs) across rural India, according to a new government report, indicating that the rising number of seats in medicine has hardly had any impact on specialised healthcare delivery beyond cities.
Rural CHCs are 30-bed facilities below district hospitals and provide secondary-level healthcare services to approximately 1.6 lakh people on average. In addition to a general duty medical officer, anaesthetist and paramedics, these are manned generally by four medical specialists: surgeon, physician, gynaecologist, and paediatrician.
The Health Dynamics of India 2022-23 report released by the Union health ministry Monday showed that only 4,413 specialist doctors of the requisite 21,964 needed in CHCs in March 2023 were available—a shortfall of 17,551 or 79.9 percent. There are 5,491 rural CHCs in 757 districts of the country.
The data also showed that the availability of specialists at 868 CHCs in urban areas was slightly better at 56 percent.
Interestingly, the statistics reveal that the crisis of specialist doctors at rural CHCs may have worsened over the years.
In comparison, the numbers show that at the primary health centres—the first point of contact between the community and a medical officer (normally an MBBS)—there is a shortfall of 976, or less than 4 percent, of doctors. To be sure, these are overall numbers and there are some states and Union Territories that are not experiencing any shortfall.
These figures suggest that, owing to the gradual rise of medical colleges in the country, there may be more MBBS doctors now available to serve in the hinterlands, but a majority of those with post-graduate (MS and MD) degrees are still shying away from serving at government facilities in rural areas.
Experts said that the figures are an indication that CHCs are failing to serve their purpose.
“These dismal statistics are a message to the government that it either needs to revise its strategy to improve specialist care in rural areas or completely shut these centres,” said public health specialist Dr Antony K.R., who is independent monitor of the Centre’s National Health Mission.
The report also shows that there are 27,304 doctors and specialists employed across 714 district hospitals in the country, against a sanctioned strength of 33,964—which means that nearly 20 percent of these seats are vacant too.
Bleak numbers
The new report, which was earlier called the Rural Health Statistics, showed that in rural CHCs, there was a shortfall of 4,578 surgeons, or 83.3 percent; 4,078 obstetricians and gynaecologists, or 74.2 percent; 4,499 physicians, or 81.9 percent; and 4,425 paediatricians, or 80.5 percent.
The number of each of these specialists required in rural CHCs is 5,491.
The situation is particularly bleak in large states such as Madhya Pradesh, Bihar, Uttar Pradesh, Rajasthan, Gujarat, and Tamil Nadu which have a shortage of 94 percent, 80.9 percent, 74.4 percent, 80.3 percent, 88.1 percent, and 85.2 percent, respectively.
Experts underline that the lack of specialist doctors in CHCs often puts unnecessary burdens on district hospitals, which are often stretched to capacity, thus depriving a large number of the rural population of specialist care closer to their homes.
Also, this shortage of specialists seems to be worsening year after year. There was, for instance, a shortfall of 17,525 specialists at CHCs in 2014-15, 17,459 in 2018-19 and 17,519 in 2020-21. It has become 17,551 now. In 2005—used as a comparative in the document—there was a shortfall of 6,110 specialists, 44 percent, against the required 13,884 specialist doctors in rural areas.
“The picture is getting gloomier every year,” said Antony. He added that states should also stop the practice of upgrading PHCs into CHCs when they cannot ensure specialist care at these centres.
Data show that 2,145 CHCs were added between 2005 and 2023, with Uttar Pradesh, Tamil Nadu, Bihar, Rajasthan, and West Bengal adding most of these facilities.
Mismatch in demand & supply
Last month, the health ministry presented statistics in Parliament that showed that India’s doctor-population ratio now is 1:836—higher than the World Health Organisation (WHO) prescribed ratio of 1 doctor per 1000 population.
The total number of registered modern medicine doctors, according to the statistics, is 13,86,136.
The data also showed that India now has 731 medical colleges offering 1,12,112 MBBS seats and 72,627 post-graduate or post-graduate equivalent seats in medicine.
In comparison, according to the details shared by the government, there were 51,348 MBBS seats and 31,185 PG seats in medicine before 2014.
The major initiatives that have led to more seats in medicine are relaxing the norms for opening and running MBBS course and allowing 1 teacher for every 3 PG students, as opposed to 1:2 ration that was prevalent earlier.
Also, diplomate degree after MBBS—Diplomate of National Board—which are run by hospitals, including large corporate hospitals, and not necessarily medical colleges, are now considered PG equivalent.
But clearly, said Dr T. Sundararaman, who has previously headed the Union government’s National Health System Resource Centre, and is now associated with Jan Swasthya Abhiyan, very few PG doctors are interested in working in rural areas.
“It is a problem that has persisted for 25 years—from the design of the health facility pyramid to a push towards privatisation, there may be a lot of reasons for the specialist crisis beyond cities,” he said.
“On many occasions, while CHCs have sanctioned posts for specialists, they are not equipped to provide specialist care, which is why PG doctors are not interested in working at such centres.”
Also, Sundararaman said, as a large number of speciality and super-speciality seats are pursued in the private sector where doctors have to spend lakhs to secure a degree, they are unlikely to see serving in a rural hospital as a lucrative prospect.
“In my view, providing for the post of a single surgeon in a CHC is not helpful as they often find it difficult to operate,” he said, adding that the functioning of CHCs needs to be reevaluated.
“It may be helpful to deploy doctors in family medicine with an upgraded skill in basic surgeries at CHCs,” he said, adding that the unified test for entrance into PG medicine (National Eligibility-cum-Entrance Test or NEET-PG) should incentivise those who commit to work in rural areas.
Antony, who has previously worked as health and nutrition specialist with UNICEF India, suggested that the national medical regulator should see that post graduate seats are increased in specialties whose pass-outs will serve at the CHCs.
“The country needs more PG seats in paediatrics, obs-gynae and general surgery as compared to other specialities because these specialists are more needed in rural areas to provide specialist care to people closer to their homes,” Antony said.
(Edited by Sanya Mathur)
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